IT’S often more revealing what people are not talking about than what they are. The Government’s lockdown restrictions on outdoor socialising, the closure of restaurants and schools, international flight controls, provoke endless debate. The evidence that this will make any difference to Covid transmission and deaths is limited to say the least but arguing about it distracts from the major driver of Covid deaths: the elderly and in particular care homes.
As supposed experts and ministers panicked over tiers and lockdowns towards the end of 2020, the high death toll in care homes attracted barely any attention outside The Conservative Woman. Public Health England figures for October to December showed that nearly one third of Covid case clusters were in care home settings, the largest identified area of Covid infections. About the same percentage of all Covid deaths have been in care homes. Per capita, care home residents are roughly 80 times more likely to have died with Covid than everyone else.
When the public inquiry into Covid comes, the failure to protect care home residents – particularly last spring – will cause a lot of back-covering and finger-pointing. The discharge of elderly hospital patients to care homes is a matter of record. On March 17, 2020, Simon Stevens, chief executive of the NHS, instructed managers urgently to discharge all hospital patients who were medically fit to leave, to free substantial numbers of hospital beds. Government guidance of April 2 (issued under the banners of the NHS, Public Health England, the Care Quality Commission and the Department of Health and Social Care) was explicit that ‘negative tests are not required prior to transfers / admissions into the care home’.
The British Medical Journal has referred to this policy as ‘reckless’. The Public Accounts Committee was equally damning, noting this practice ‘remained in force even after it became clear people could transfer the virus without ever having symptoms’. Compounding this was a substantial reduction in hospital admissions among care home residents in March and April. Elective admissions reduced to 58 per cent of the five-year historical average and emergency admissions to 85 per cent. With so many people not receiving hospital care, it’s not surprising that from March 21, 2020 to February 5, 2021 there were 27,106 excess deaths in care homes (compared with the previous five-year average), 99 per cent of which were with Covid. The number of excess deaths in this period amounts to 5 per cent of all care home residents.
By mid-April 2020, the failings of this approach were evident as reported by The Conservative Woman, warning of a ‘care home Chernobyl’, and policy was changed to test everyone prior to admission to a care home, including on discharge from hospital. However things went from bad to worse, highlighted again by TCW, with visiting by relatives in effect banned. Government guidance stated that care homes should advise family and friends not to visit except in exceptional circumstances though even their own advisers doubt its efficacy; the Scientific Advisory Group for Emergencies (Sage) assessed that the prohibition of visits would likely have a low impact on transmission but ‘substantial social and emotional impact on residents and, for end of life patients in particular, relatives’.
The impact of the confinement on care home residents is barely understood but what is known is concerning, particularly for those suffering from dementia. One study found that more than half of patients experienced a worsening or onset of behavioural disturbances, (such as agitation/aggression, apathy). A worsening of cognitive symptoms, particularly of memory and orientation abilities, was reported in nearly one-third of the sample. An Alzheimer’s Society survey of 128 care homes reveals nearly 80 per cent had seen a deterioration in the health of their residents with dementia owing to lack of social contact.
In June the Government created a social care sector Covid-19 task force to ‘support the national campaign to end transmission in the community and also consider the impact of Covid-19 on the sector over the next year and advise on a plan to support it through this period’. The report states that ‘We heard, consistently, of the importance to families of visiting their loved ones in care homes . . . In some cases, they are an integral part of a care plan to maintain the safety and wellbeing of residents’. The task force published its report in late September 2020, identifying a total of 52 recommendations of which only one referred to visitors: ‘Testing of regular family visitors to care homes should be reviewed by Sage considering risks associated with visitors, risks to residents of not being able to see their families and circumstances where relatives’ care and support in the homes is an integral part of the care plan’, a lot of bureaucratspeak that says everything and nothing at the same time.
It need not be like this. In the Netherlands, a protocol has been developed to allow visits with restrictions (eg one nominated visitor per care home resident, limited visitors at any one time, distancing rules maintained, visitors free of Covid symptoms). An initial study indicated this arrangement did not lead to an increase in Covid cases. A small charity called John’s Campaign has been doing an admirable job holding the Government’s feet to the fire on this, with the threat of legal action forcing changes to guidance on care home visits. They provide a guide on what to do if anyone is refused a visit to a relative in a care home.
However, as Public Health England figures show, care home infections remained high through the autumn and early winter of 2020 and increased further this January. In many care homes, basic safety procedures, such as isolating infected residents, were not followed, but probably more significantly Covid-positive hospital patients have again been admitted to care homes, with the Government offering its clinical negligence and employers’ and public liability as an incentive. And so Covid deaths in care homes continued to rise in January and taxpayers await the bill from legal claims that may come.
This treatment of care homes as something akin to collateral damage is not unique to Britain. Perhaps the most brazen example is in New York State where Governor Mario Cuomo has claimed that allegations of nursing home deaths being caused by his order to put patients infected with coronavirus back in facilities were ‘a conspiracy theory’. This bluster is falling apart as his own Attorney General has produced a report stating that nursing home deaths due to Covid – currently estimated at 15,000 – may be understated by up to 50 per cent and is investigating complaints about nursing home practices.
Pressure on the UK Government on this issue is starting to mount, with six charities calling for visits to care homes by relatives to begin in early March and it is reported that the Government will announce today that each care home resident in England will be allowed one designated visitor from 8 March with a number of other restrictions. Finding a means of allowing visits whilst protecting care home residents may be challenging yet the subject gets relatively little attention. This is one of the consequences of obsessing over Covid policy measures that are largely superfluous to controlling the spread of the virus: you take your eye off things that could make a real difference to life and its quality.